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Housing Application
First Name
Last Name
Date of Birth
*
required
Email Address
Current Address
Phone
Emergency Contact Number
Emergency Contact Relationship
Emergency Contact Name
Background
Have you Previously Lived in a recovery or Sober living home?
*
Required
Yes
No
Are you currentlyinTreatment or Have you completed a Program
*
Required
In Treatment
Completed
Neither
If Yes where and When
Program Name
Completion/Discharged Date
*
required
Do you identify as a:
*
Required
Veteran
Senior (65+)
Justice Involved Recently Incarcerated
Person with Disability
None of the Above
Do you have any pending legal Matters(Probation,Parole,Court)
*
Required
Yes
No
If Yes , Please Explain
Health & Recovery
Date of Last Substance use
*
required
Primary Substance(s) used
Do you have a mental health diagnosis
Yes
No
Are you currently on medication-assisted treatment (MAT)?
*
Required
Yes
No
If Yes , List diagnosis (optional)
If Yes, Which Medication
List any current prescribed medications
Do you have any physical limitations, ormedical needs
Yes
No
If Yes, describe
Income Support
Whats you currentIncome Source
*
Required
SSI/SSDI
Veterans Benefits
Employment
Family Support
Unemployment
Other
Monthly Income Ammount (approx) :$
Are you working wiht a case manager or agency
Yes
No
If yes, Provide contact in (name,phone,email)com
Program Fit
Why are you seeking housing with Serenity Roots
What are your personal goals for the next 6-12 Months
Are you willing to follow house rules & Reain Drug and Alchol free?
*
Required
Yes
No
Pefered Move-In Date
*
required
Upload Documents
Upload ID (US ID)
Upload File
Upload supported file (Max 15MB)
Upload Discharge Summory (If applicable)
Upload File
Upload supported file (Max 15MB)
Upload Proof of Income or Benefits
Upload File
Upload supported file (Max 15MB)
Upload Referral Latter (If applicable)
Upload File
Upload supported file (Max 15MB)
Signature & Consent
I certify that the information provided is true and complete to the best of my knowledge.
I understand that submission of this application does not guarantee placment.
I consent to be contacted by Serenity Roots regarding this application.
Signature
Clear
Date Submitted
*
required
Submit
Thanks for submitting!
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